1. Observations from CTRs & the nurse’s role Dave Atkinson

2. Placing the CTR in context:  Delivery systems  CPA  Needs assessment  Care planning  Coordination  Reviews  Treatment Plans  Care Plans  Positive Behaviour Support Plans  Health Action Planning  Person centered planning  Others…  Reviews  MHA Tribunals  Managers reviews  CPA reviews  MDT meetings  Ward rounds  Person centered reviews  Etc… Care and Treatment Reviews Structured approach… Comprehensive overview of: the person, the people around them, their difficulties & circumstances, a formulation, the treatment plan & whether it can safely be delivered in the community.

3. CPA  Components of the CPA care plan (MHA CoP 2015):  A treatment plan detailing medical, nursing and psychosocial support to meet needs  Details of prescribed medications  Actions to address physical health problems or reduce the likelihood of health inequalities  Details as to how the person will be supported to achieve their own personal goals  Support in relation to social needs (housing, occupation, finances etc)  Support to carers  Actions in response to deterioration  What to do in a crisis  Aligned to PBS Plan

4.  The CPA process was run, and meetings chaired, by [the hospital]  There must be assurance that the protection of vulnerable adults from abuse is clearly built into the CPA process  Very limited examples of senior commissioning participation from the local commissioning team at the review meetings  The implementation of the CPA should be required and monitored as part of the contractual agreement by commissioning authorities  Lack of challenge from care coordinators  Confusion around the role of the CPA Care Coordinator… which has been exacerbated when the placement is an Out of Area Treatment... an assumption that his role automatically fell to the receiving service  The hospital’s CPA process did not interface with local mental health service processes and that of the placing authorities Why CPA is often not enough:  The CPA process was run, and meetings chaired, by [the hospital]  There must be assurance that the protection of vulnerable adults from abuse is clearly built into the CPA process  Very limited examples of senior commissioning participation from the local commissioning team at the review meetings  The implementation of the CPA should be required and monitored as part of the contractual agreement by commissioning authorities  Lack of challenge from care coordinators  Confusion around the role of the CPA Care Coordinator… which has been exacerbated when the placement is an Out of Area Treatment... an assumption that his role automatically fell to the receiving service  The hospital’s CPA process did not interface with local mental health service processes and that of the placing authorities

5. When CPA fails:  Key lessons:  Failure to follow policy  Policies not fit for purpose  Hospitals not linking with communities  Placing authorities ‘opting out’  Independent hospitals owning the process  Tokenistic CPA procedures and approaches to involvement  Cursory knowledge of CPA  Reviews not led by case / care managers  Not linked to safeguarding processes  Rigid review schedules and formats  Lack of engagement of relevant parties

6. Care & Treatment, delivery and coordination

7. The value of CTRs  Not driven by the hospital  Are discharge focused  Generate creative solutions e.g. challenging traditional forensic pathways  Overcome barriers to progress  Improve timely access to treatment  Held responsively  Include holistic perspectives on user needs and wellbeing  Include service quality and performance monitoring (outcomes & process)

8. The value of CTRs  Ensure senior commissioning participation  Include external challenge  Include independent scrutiny  Are person centered  Place user and family perspectives first  Tend to be well attended  The ability to escalate unresolved issues via NHSE  Feed CPA care plans

9. CTR positive examples  Young man with mild learning disability and autism. On transition to adult services, amidst disruption at home, became depressed and presented behaviours that challenge. Despite initial home treatment, he was subsequently detained and admitted to an ATU. After a period of treatment he made good progress and all agreed for a discharge to a small residential placement. Significant delays arose due to funding problems – caused him and his family to become distressed. A CTR was requested and within 2 weeks, the funding problems had been resolved and he was successfully discharged.  Young man with mild learning disability. Lived alone with some family support. He disclosed that he had been accessing pornographic child images online. He then became highly anxious and was admitted to an ATU. Quickly he appeared to calm and so was discharged back home with support from the local community team. A few weeks later, a similar incident occurred and an admission was again suggested. This time a CTR was held and recommended that he be maintained in his home with community team support but with additional social support – especially at weekends. Admission was avoided, the local authority funded additional support and he continues to live at home.

10. Focus on care and treatment and the CTR will take care of itself:  Human rights based approach  Ensuring least restrictive settings  Reduce restrictive practices / interventions  Delivering positive and proactive care  Ensuring a focus on valued outcomes  Strong collaborative relationships with the people you support, their families and carers  Care planning: the role of CPA  Instrumental in discharge planning  Needs community care coordinator  Should be person centered  Ensure CPA delivers on the CTR recommendations

11. Preparing for the review  Be clear about the purpose and aims of the review  Don’t just refresh care plans because there’s a CTR the next day!!  Be prepared to present your own professional opinion  Recognise the value of challenge to your practice  A CTR provides nurses an important opportunity for reflective learning  Know the person you support  Prepare them for the CTR  Communication is key  Present information in an appropriate format  Make sure they understand what a CTR is, what it can achieve  Allay anxieties wherever possible

12. After the review  Be clear about the outcomes of the review  Record accurately  Ensure full and accurate recording and plans for subsequent action  Think about CPA as the vehicle to drive and coordinate CTR recommendations – consider whether CPA is working in your service!!